Health Professionals' Roles in Animal Agriculture, Climate Change, and Human Health

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Current Issues Health Professionals’ Roles in Animal Agriculture, Climate Change, and Human Health Aysha Z. Akhtar, MD, MPH, Michael Greger, MD, Hope Ferdowsian, MD, Erica Frank, MD

Abstract: What we eat is rapidly becoming an issue of global concern. With food shortages, the rise in chronic disease, and global warming, the impact of our dietary choices seems more relevant today than ever. Globally, a transition is taking place toward greater consumption of foods of animal origin, in lieu of plant-based diets. With this transition comes intensiﬁcation of animal agriculture that in turn is associated with the emergence of zoonotic infectious diseases, environmental degradation, and the epidemics of chronic disease and obesity. Health professionals should be aware of these trends and consider them as they promote healthier and more environmentally-sustainable diets. (Am J Prev Med 2009;36(2):182–187) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Introduction ment of Agriculture (USDA), partly due to the high throughput of animals slaughtered for food. ver 9 billion land animals are slaughtered for food annually in the U.S.,1,2 approximately 1 Omillion per hour. The U.S. is home to only Climate Change and Environmental Degradation about 5% of the global population but produces nearly As a result of the steady rise in animal-product promo- 15%of the world’s meat supply,3 and the average Amer- tion and demand, traditional farming practices in the ican consumes 110 pounds of red meat and 74 pounds latter half of the last century were replaced in the U.S. of poultry per year.4 Global demand for meat has largely by immense, intensive animal operations; in the increased substantially in recent decades. Between 1975 developing world, they are being replaced at a rate of and 1990, per capita meat consumption increased an more than 4% a year.6 The industrialization of animal estimated 1.4% per year.5 World meat production is 6 agriculture is an important contributor to global envi- expected to double by 2020, in part due to national ronmental degradation and climate change.19 and international regulations that allow animal agri- Animal agriculture accounts for 37%, 65%, and 64% business to externalize costs and to aggressive corpo- 7–10 of anthropogenic methane, nitrous oxide, and ammo- rate marketing campaigns. For example, the U.S. nia emissions, respectively, from ruminant fermenta- Federal Government subsidy system and food assistance tion, livestock waste, fertilizer use and other factors.20 programs heavily promote the production and distribu- 11–17 Methane and nitrous oxide have 23 and 296 times, tion of meat and dairy products, over plant-based 20 respectively, the global warming potential of CO2. In foods. 2006, the UN Food and Agriculture Organization Recently an investigation of a California dairy cow (FAO) declared that animal agriculture contributes slaughter plant by the Humane Society of the U.S. 18% of annual anthropogenic greenhouse gas emis- (HSUS) documented the abuse and slaughter of cows sions, measured in CO2-equivalents, more than that of too sick or injured to walk, leading to the recall of 143 the worldwide transportation sector.20 The public million pounds of beef in February 2008, the largest in health effects of climate change are already being felt 18 U.S. history. The investigation raised considerable around the world and the UN Intergovernmental Panel concern about the safety of the meat supply, including on Climate Change projects that they will worsen inadequate regulatory oversight by the U.S. Depart- considerably.21–26 Animal agriculture constitutes 30% of the total land surface, the largest use of land by humans.20 Thirty- From The Washington Center for Clinical Research (Akhtar, Ferdow- three percent of total arable land is used to produce sian), the Humane Society of the United States (Greger), Washing- 20 ton, DC; and the School of Population and Public Health, University feedcrops, with energy input that far outweighs the of British Columbia (Frank), British Columbia, Canada output. Approximately 70% of previously forested land Address correspondence and reprint requests to: Aysha Z. Akhtar, in the Latin American Amazon is used as grazing MD, MPH, The Washington Center for Clinical Research, 5100 Wisconsin Avenue NW, Suite 400, Washington DC 20016. E-mail: pastures, with the remainder being used largely for [email protected]. feedcrop production.20 Annually in the U.S., 45 million

182 Am J Prev Med 2009;36(2) 0749-3797/09/$–see front matter Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine doi:10.1016/j.amepre.2008.09.043 tons of plant protein are used to produce 7.5 million promoting antibiotics.40 Half of all U.S. antimicrobials tons of animal protein.27 Most of this plant protein are fed to farm animals.41,42 The mass use of clinically could instead be consumed directly by humans and significant antibiotics in animal agriculture selects for could, in part, alleviate some growing concerns about a drug-resistant pathogens and mobile genetic elements global food shortage. carrying resistance determinants that may be responsi- Animal agriculture consumes 70% of the fresh water ble for the majority of the increases in antibiotic- and contributes extensively to land, air, and water resistant human isolates reported.43,44 pollution.20 Pesticides and fertilizers, including manure, may contaminate waterways. In the U.S., animal Chronic Diseases agriculture is responsible for 37% of pesticide use and 32% and 33%, respectively, of the nitrogen and phos- Historically, chronic diseases, including obesity, have phorus loads found in fresh water sources.20 Surveys in plagued the developed world, whereas developing North Carolina and Iowa found substantial increases in countries have been more affected by communicable asthma symptoms in children residing near industrial diseases. However, obesity and chronic diseases are pig operations and decreased quality of life measures in increasingly a concern in developing nations.10 An surrounding communities.28–30 The combined envi- estimated 65% of U.S. adults are overweight or obese,45 ronmental impact of animal agriculture has led the and globally, more than 1 billion adults are over- FAO to declare in 2006 that “the livestock sector weight.46 Especially concerning is the increasing global emerges as one of the top two or three most significant prevalence of childhood obesity.46 Obesity increases contributors to the most serious environmental prob- the risk for diabetes, arthritis, asthma, hypertension, lems, at every scale from local to global.”20 and hypercholesterolemia.47Worldwide, cardiovascular disease, cancer, and diabetes are three of the four main causes of death.48 Emerging and Re-Emerging Infectious Diseases The worldwide transition from a predominantly In 2004, the WHO, the World Organization for Animal plant-based diet to a diet high in meat has been Health, and the FAO reported that the increasing identified as a noteworthy contributor to the rise in global demand for animal protein in the human diet, chronic disease.10,49 Animal products are the main associated with the expansion and intensification of source of saturated fats that promote cardiovascular animal agriculture, long-distance live-animal transport disease49 and the sole source of cholesterol intake. and other factors, were in part responsible for the Comparative studies reveal that those who follow plant- emergence of zoonotic diseases.31 Industrial agricul- based diets generally have lower weights than those who ture practices have been blamed for the emergence of do not,50,51 even across ethnic groups.50 While not bovine spongiform encephalopathy, multidrug-resistant conclusive, evidence suggests that the increase in world- foodborne bacteria, and highly pathogenic strains of wide obesity and diabetes may in part be associated with avian influenza.32 increased animal-product consumption, in addition to An estimated 76 million Americans are stricken with decreased exercise and other factors.10 a foodborne illness every year.33 Worldwide, foodborne The classic study by Armstrong and Doll52 revealed microbial disease kills an estimated 20 million people significant association between meat consumption and annually, with animal products topping the list of colon cancer incidence in over 25 countries. Studies in causes.34 The global rise in the incidence of foodborne Japan revealed a rising incidence in colorectal cancer diseases is attributed to greater consumption of animal with greater adoption of Western dietary habits and products, the intensification of farm operations, and consumption of meat, milk, eggs, and fats and oils.53,54 rising temperatures.35,36 Other studies revealed similar associations between Annually, more than a ton of farm-animal manure is rising meat consumption in Asian countries and colon produced per capita in the U. S.37 Farm-animal manure cancer incidence and/or mortality.55,56 Although con- is the source of more than 100 zoonotic pathogens,38 founding factors must also be considered, these and which may contaminate food and water supplies. other studies collectively provide strong evidence of the Manure-contaminated irrigation water, for example, causal link between meat and colorectal cancer.57–59 In was likely the source of the largest recorded outbreak of 2007, the World Cancer Research Fund and the Amer- Escherichia coli O157:H7, affecting more than 7000 ican Institute for Cancer Research panel report con- schoolchildren in Japan.39 cluded that there was convincing evidence to limit red Under conditions ripe for zoonotic pathogen emer- meat intake, completely avoid processed meat, and gence and transmission, such as the high-density con- follow a plant-based diet to reduce the overall risk for finement of farm animals under unhygienic condi- cancer.59 tions,6 farm animal growth rates may be impaired in Consumption of various animal products is also light of the infectious load to which they are exposed. associated with increased risk for other cancers. Endo- This may be mitigated by a constant influx of growth- metrial cancer risk is associated with increased intake of

February 2009 Am J Prev Med 2009;36(2) 183 total energy, fat, and protein from animal sources.60 A schools receive these commodities, possibly contribut- meta-analysis found an increased endometrial cancer ing to the fact that approximately 80% of elementary risk with increased meat, particularly red meat, con- and secondary schools violate limits on total and satu- sumption.61 Dairy-product consumption has been asso- rated fat content.85,86 ciated with prostate cancer62–64; the European Prospec- International studies have demonstrated that tive Investigation into Cancer and Nutrition study of changes in agricultural subsidy policy can mitigate 142,251 men found that high intake of dairy calcium rising chronic disease rates. In Poland, the withdrawal and protein increased the risk of prostate cancer.65 of large animal-product subsidies led to decreased Calcium from nondairy foods was not associated with saturated fat intake and increased fruit and vegetable increased cancer risk. In recent studies, breast cancer intake, followed by a subsequent decrease in ischemic risk has been associated with higher intake of processed heart disease mortality.87 After long periods of in- meat, total meat, and/or red meat,66–69 and with creases, mortality from heart disease and stroke de- higher intakes of total and saturated fats.69 creased by 25% and 10%, respectively, between 1991 Healthcare costs attributable to meat consumption and 1994 among those aged 45–64. Between 1986 to are substantial, estimated in the U.S. at between $29 1990 and 1994, there was a 23% decrease in animal fat billion and $61 billion per year, in 1992 dollars.70 In availability, 48% increase in vegetable fat availability, contrast, many studies suggest that those who consume and an almost 50% increase in importation of certain plant-based diets have decreased risk, mortality, and/or fruits. In Eastern European countries in 2002, substan- progression of cardiovascular disease,71–73 diabetes,74 tial decline in cardiovascular mortality was associated certain cancers,75–77 and obesity.78,79 Diets high in with increased consumption of plant oils rich in alpha- legumes, whole grains, fruits, and vegetables appear to linolenic acid.88 be protective against these chronic diseases.80–82 In addition to involvement in food policy, healthcare providers should have a coordinated voice in environmental policy. The APHA has a policy calling for a What Healthcare Providers Can Do moratorium on factory farms.89Other physician and Physicians and other healthcare providers can play a healthcare groups could follow suit. Recently, the U.S. critical role in promoting healthier food options and Environmental Protection Agency proposed that live- reversing the trend toward greater livestock produc- stock farms be exempt from reporting emissions of tion. Healthcare providers can help accomplish this in ammonia, hydrogen sulfide and other pollutants.90 three main ways: as advocates, as providers, and as role Input from healthcare providers is needed to prevent models. such regressions in environmental protections that may As evidence-based advocates, healthcare providers otherwise pose adverse public health consequences. can provide medical input into federal policies that As healthcare providers, all physicians, nurses, and affect nutrition and health. The American Public physicians assistants can incorporate nutrition counsel- Health Association (APHA), the American Medical ing into routine care. When physicians advise their Association, and the President’s Cancer Panel of the patients about nutrition, incidence of chronic diseases National Cancer Institute have highlighted the impor- may decline.91–94 Despite the potential of counseling to tance to the obesity epidemic of federal food policy, as improve dietary practices, many primary care physi- well as the importance of physician and public health cians never include nutrition or dietary counseling in leadership in federal nutrition policy reform.8,83,84 Cur- their patient visits, or include only perfunctory coun- rently, U.S. agricultural policy disparately promotes seling.95–98 Medical societies can facilitate the incorpo- animal products, in contradiction with the U.S. Dietary ration of routine nutrition counseling by advocating for Guideline’s emphasis on plant-based foods. A calcu- greater physician reimbursement for such care. lated 73% of over $60 billion in federal commodities Finally, as individuals, healthcare providers can serve payments for domestic food consumption between as examples and leaders when they alter their own 1995 and 2005 supported the production of meat, eggs, lifestyle behaviors. One of the least exploited and most and dairy, either directly or indirectly through feed- significant and consistent counseling predictors is the crop supports.11–17 Less than 0.5% of federal subsidies positive effect of a physician’s healthy personal practices is allocated to fruits and vegetables. on his or her clinical prevention-related practices.99–103 After the California slaughter plant investigation and Specifically, physicians’ healthy dietary practices posi- meat recall of February 2008, public food safety con- tively affect their clinical nutrition counseling atti- cerns were especially heightened, since a large fraction tudes99 and practices91,99,102,103; and U.S. medical stu- of the meat that was recalled had already been distrib- dents find nutrition counseling more relevant if they uted to school lunch programs.18 Surplus agricultural consume more fruits and vegetables.104 products, largely animal products high in fat and Health professionals can set an example by consum- cholesterol, are distributed through school lunch and ing fewer animal products at home and at work, and by other food assistance programs. An estimated 100,000 demanding healthier plant-based options in hospital

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